Jennifer McKell

Financial incentives for smoking cessation in pregnancy: Randomised controlled trial

Objective To assess the efficacy of a financial incentive added to routine specialist pregnancy stop smoking services versus routine care to help pregnant smokers quit. Design Phase II therapeutic exploratory single centre, individually randomised controlled parallel group superiority trial. Setting One large health board area with a materially deprived, inner city population in the west of Scotland, United Kingdom. Participants 612 self reported pregnant smokers in NHS Greater Glasgow and Clyde who were English speaking, at least 16 years of age, less than 24 weeks pregnant, and had an exhaled carbon monoxide breath test result of 7 ppm or more. 306 women were randomised to incentives and 306 to control. Interventions The control group received routine care, which was the offer of a face to face appointment to discuss smoking and cessation and, for those who attended and set a quit date, the offer of free nicotine replacement therapy for 10 weeks provided by pharmacy services, and four, weekly support phone calls. The intervention group received routine care plus the offer of up to £400 of shopping vouchers: £50 for attending a face to face appointment and setting a quit date; then another £50 if at four weeks’ post-quit date exhaled carbon monoxide confirmed quitting; a further £100 was provided for continued validated abstinence of exhaled carbon monoxide after 12 weeks; a final £200 voucher was provided for validated abstinence of exhaled carbon monoxide at 34-38 weeks’ gestation. Main outcome measure The primary outcome was cotinine verified cessation at 34-38 weeks’ gestation through saliva (<14.2 ng/mL) or urine (<44.7 ng/mL). Secondary outcomes included birth weight, engagement, and self reported quit at four weeks. Results Recruitment was extended from 12 to 15 months to achieve the target sample size. Follow-up continued until September 2013. Of the 306 women randomised, three controls opted out soon after enrolment; these women did not want their data to be used, leaving 306 intervention and 303 control group participants in the intention to treat analysis. No harms of financial incentives were documented. Significantly more smokers in the incentives group than control group stopped smoking: 69 (22.5%) versus 26 (8.6%). The relative risk of not smoking at the end of pregnancy was 2.63 (95% confidence interval 1.73 to 4.01) P<0.001. The absolute risk difference was 14.0% (95% confidence interval 8.2% to 19.7%). The number needed to treat (where financial incentives need to be offered to achieve one extra quitter in late pregnancy) was 7.2 (95% confidence interval 5.1 to 12.2). The mean birth weight was 3140 g (SD 600 g) in the incentives group and 3120 (SD 590) g in the control group (P=0.67). Conclusion This phase II randomised controlled trial provides substantial evidence for the efficacy of incentives for smoking cessation in pregnancy; as this was only a single centre trial, incentives should now be tested in different types of pregnancy cessation services and in different parts of the United Kingdom. Trial registration Current Controlled Trials ISRCTN87508788.

Bereavement through substance use: findings from an interview study with adults in England and Scotland

Abstract Background: Deaths associated with alcohol and/or drugs belong to a category of ‘special’ deaths due to three characteristics: traumatic circumstances of the death, stigma directed to both the bereaved and the deceased, and resulting disenfranchised grief experienced by the bereaved. These factors can impede those who are bereaved in this way from both grieving and accessing support. In response to a lack of research in this area this paper reports on an interview study that has aimed to better understand the experiences and needs of this neglected group of bereaved people. Method: Interviews with 106 adults (parents, children, spouses, siblings, nieces and friends) bereaved through substance use in Scotland and England. Results: Five themes describe interviewee experiences: possibility of death, official processes, stigma, grief and support. These findings suggest what is dominant or unique in this group of bereaved people; namely, that living with substance use (including anticipatory grief), experiencing the subsequent death (often traumatic and stigmatised) and the responses of professionals and others (more likely negative than positive) can disenfranchise grief and negatively impact bereavement and seeking support. Conclusions: This article describes a large and unique sample, the largest in the world to be recruited from this population. Our study raises awareness of a hitherto largely ignored and marginalised group of bereaved people, highlighting what might be particular to their bereavement experience and how this may differ from other bereavements, thereby providing an evidence base for improving the availability, level and quality of support.

Combining school and family alcohol education: a systematic review of the evidence

Purpose – The purpose of this paper is to map and identify evidence for effective components of combined school and family alcohol education interventions. The paper describes current practice, evaluative evidence of its effects, and highlights specific elements of school and family linked education associated with effective prevention or reduction of alcohol misuse by young people aged 11-18 years. Design/methodology/approach – This paper takes the form of a systematic review. Findings – The review found evidence of small positive effects for interventions delivered over short and longer term duration and low and higher levels of direct contact with students and families. Family-based elements that correlated with positive effects were targeting information and skills development, family communications, and stricter parental attitudes to alcohol misuse. School-based components which involved life skills and social norms approaches were associated with reductions in risky behaviours. Weaker evidence indic...

Young Women Smokers’ Perceptions and Use of Counterfeit Cigarettes: Would Plain Packaging Make a Difference?

Opponents of plain tobacco packaging argue that it would make production of counterfeit tobacco products cheaper; lower costs for consumers; confuse consumers in respect to product authenticity; and increase appeal and purchase of counterfeit tobacco. We explored the last of these contentions with young women smokers (N = 49), aged 16–24 years, recruited in Glasgow (Scotland). Participants were firstly asked about their perceptions and purchase of counterfeit cigarettes. Each group was then shown a mock display of legitimate and counterfeit plain cigarette packs. All the packs shown were the same colour (brown) with the only difference being the price and brand name. Participants were asked what brand they would smoke if all cigarettes came in brown (plain) packaging. Purchase of counterfeit cigarettes was lower for 16–17 year olds than 18–24 year olds. Perceptions of counterfeit cigarettes were negative, with concerns expressed about content and taste. All participants said that if pack appearance was standardised they would continue to smoke the same brand of legitimate cigarettes that they currently smoke or down-trade to cheaper legitimate brands. Non-users of counterfeit cigarettes indicated that they would remain non-users should all cigarettes come in uniform packaging. Counterfeit users, at least those willing to smoke counterfeit cigarettes again, indicated that they would still buy counterfeit cigarettes if pack appearance was standardised, primarily due to the lower price. For young women smokers in this study, plain packaging had no bearing on perceived appeal of counterfeit cigarettes.

Pathways back to work for problem alcohol users

The relationship between alcohol misuse, employment and unemployment is complex. Alcohol misuse is correlated with a range of other problems, including, for example, drug misuse, mental health problems and social deprivation. Together these can be a barrier to accessing and sustaining employment. The aim of this study was to explore these issues with a sample of adults in the UK who were currently accessing treatment for an alcohol problem. The study involved a systematic literature review followed by qualitative research with 53 treatment service clients and 12 professionals across 5 research sites in England, Scotland and Wales. The findings focus on the main facilitators and barriers, both individual and organisational, for returning to work identified by interviewees. Some of the facilitators and barriers identified were similar to those described in the literature for other groups of unemployed adults. Others were more specific to alcohol misusers; for example, the stigma experienced by interviewees as a result of the views of others regarding substance misuse, the nature of recovery from addiction and the challenges posed by the prevalence of coexisting mental and physical health problems. Despite the problems faced by many of the study participants, however, the majority were eager to return to work, and this desire to gain employment is discussed in the context of ongoing welfare reform in the UK.

Bereavement following a fatal overdose: The experiences of adults in England and Scotland

Abstract Aims: Overdoses contribute disproportionately to drug-related deaths (DRDs) in the UK, yet little is known about the experiences and needs of those who are bereaved by such deaths, and how their experiences and needs might differ from other bereavements associated with substance use. Methods: An interview study with 32 adults in England and Scotland (part of a larger study). Findings: Five themes describe the core experiences of this group of bereaved people: drug use, the death, official processes, stigma, and overdose awareness and prevention. Together, these findings offer new insights in to the key features of this type of bereavement; for example, living with substance use including previous overdoses, difficult circumstances surrounding the death, having to negotiate the complex procedures involved in processing the death, the stigma such deaths attract, and feelings of guilt, self-blame and an unworthiness to grieve. Conclusions: There are ways in which bereavement following an overdose differs from bereavement following other deaths associated with alcohol or drugs. Understanding the experiences and needs of this marginalised group can help improve support for them. Furthermore, this group’s experience of witnessing and/or responding to previous overdoses indicates the value in prevention programmes targeting relatives/friends.

Delivery of alcohol brief interventions in community-based youth work settings: exploring feasibility and acceptability in a qualitative study

BackgroundAlcohol Brief Interventions (ABIs) are increasingly being delivered in community-based youth work settings. However, little attention has been paid to how they are being implemented in such settings, or to their feasibility and acceptability for practitioners or young people. The aim of this qualitative study was to explore the context, feasibility and acceptability of ABI delivery in youth work projects across Scotland.MethodsIndividual, paired and group interviews were conducted with practitioners and young people in nine community projects that were either involved in the delivery of ABIs or were considering doing so in the near future. A thematic analysis approach was used to analyse data.ResultsABIs were delivered in a diverse range of youth work settings including the side of football pitches, on the streets as part of outreach activities, and in sexual health drop-in centres for young people. ABI delivery differed in a number of important ways from delivery in other health settings such as primary care, particularly in being largely opportunistic and flexible in nature. ABIs were adapted by staff in line with the ethos of their project and their own roles, and to avoid jeopardising their relationships with young people. Young people reacted positively to the idea of having conversations about alcohol with youth project workers, but confirmed practitioners’ views about the importance of these conversations taking place in the context of an existing trusting relationship.ConclusionABIs were feasible in a range of youth work settings with some adaptation. Acceptability to staff was strongly influenced by perceived benefits, and the extent to which ABIs fitted with their project’s ethos. Young people were largely comfortable with such conversations. Future implementation efforts should be based on detailed consideration of current practice and contexts. Flexible models of delivery, where professional judgement can be exercised over defined but adaptable content, may be better appreciated by staff and encourage further development of ABI activity.

A stop smoking in schools trial (ASSIST) a decade on: insights from a mixed method process evaluation

Background: ASSSIT (A Stop Smoking in Schools Trial) is a UK peer led, school based, smoking prevention programme that encourages the dissemination of non-smoking norms among 11-13 year olds. It is based on strong evidence, with results from a large cluster randomised trial showing a reduction in smoking uptake. However, data for this trial was collected in 2002-2004 and since then implementation of tobacco control policy in the UK has resulted in a further decline in adolescent smoking prevalence. This presentation will present data from an evaluation of ASSIST in Scotland, the first national evaluation of ASSIST since the original RCT. Methods: Mixed method study involving a before and after school survey (n=2166 at follow-up), in-depth interviews, paired interviews, mini focus groups, observation with school staff, trainers, students, policy and commissioning leads (n=101). Results: Three different delivery models were piloted. This did not impact on fidelity or acceptability which was rated highly. Partnership working, from the onset, was viewed as being key to successful delivery and securing school participation. Feedback was overwhelmingly positive regarding the wider benefits of taking part in ASSIST for peer supporters (i.e. personal and communication skills) but also for the school and communities. There was less certainty regarding the extent of message diffusion and the impact this may have an adolescence smoking. Student survey results showed no significant change in self-reported smoking between baseline (2.5%) and follow-up (3%) and conversation recall with a peer supporter was low at 9%. Conclusions: ASSIST is a well delivered, popular programme with additional benefit for students, their wider social network, school and community. Yet, there is uncertainty regarding the extent of message diffusion within the school year which raises questions around the continued contribution of the programme to lowering the adolescent smoking rates. Further research is needed to update the existing evidence-base.

Service failures and challenges in responding to people bereaved through drugs and alcohol: An interprofessional analysis

ABSTRACT This article reports findings from the first two stages of a three-stage qualitative study which considered the role of services, including public, private and charitable organisations, in responding to the needs of adults bereaved following the drug and/or alcohol-related death of someone close. The study, the first of its kind to explore the landscape and role of services in substance use deaths, was conducted over two sites: south west England and Scotland. In stage 1 of the research, adopting both convenience and purposive sampling, data were collected via semi-structured interviews on experiences and support needs of bereaved individuals (n = 106). In stage 2, six focus groups were conducted with a purposive sample of practitioners (n = 40), including those working for the police, coroner’s service, procurator fiscal depute (Scotland), health service, funeral service, press, clergy, Public Health England, Drugs Policy Unit, bereavement counselling/support and alcohol and drug treatment services, to investigate how services may better respond to this bereavement. Thematic analysis from both data-sets identified two overarching themes. The first, focusing on practitioner responses, captures how these bereaved people may meet with inadequate, unkind, and discriminatory responses from services. Having to navigate unfamiliar, fragmented, and time-consuming procedures compounds the bereaved’s distress at an already difficult time, illustrated by a ‘mapping’ of relevant services. The second relates to challenges and opportunities for those responding. Service failures reflect practitioners’ poor understanding of both substance use bereavement and the range of other practitioners and services involved. Those bereaved are a poorly understood, neglected and stigmatised group of service users. There is a need for services to respond without judgement or insensitive language, and provide information about, communicate and work closely with, other services despite differences in working practices and cultures. These recommendations could positively affect bereaved peoples’ experiences, alleviating stress and overwhelm at a particularly vulnerable time.

Barriers and facilitators to smoking cessation in pregnancy and in the post-partum period: The health care professionals’ perspective

Objectives Health care professionals and the health care environment play a central role in protecting pregnant and post‐partum women and their infants from smoking‐related harms. This study aimed to better understand the health professionals perspective on how interactions between women, health care professionals, and the environment influence how smoking is managed. Design Semi‐structured interviews and focus groups. Methods Data were from 48 health care staff involved in antenatal or post‐partum care at two UK sites, including midwives, obstetricians, health visitors, GPs, pharmacists, service commissioners, and Stop Smoking Service (SSS) advisors and managers. Thematic analysis was guided by a social–ecological framework (SEF). Results Themes were divided across three SEF levels and represented factors connected to the management of smoking in the health care context and the beliefs and behaviour of pregnant or post‐partum smokers. Organizational level: Service reconfigurations, ‘last resort’ nicotine replacement therapy prescribing policies, and non‐mandatory training were largely negative factors. There were mixed views on opt‐out referral pathways and positive views on carbon monoxide monitoring. Interpersonal level: Protection of client–professional relationships often inhibited frank discussions about smoking, and weak interservice relationships affected SSS referral motivation and quality. Individual level: Professionals felt community midwives had primary responsibility for managing smoking, although midwives felt underskilled doing this. Midwives’ perceived priority for addressing smoking was influenced by the demands from unrelated organizational initiatives. Conclusions Opportunities to improve clinical support for pregnant smokers exist at organizational, interservice, and health care professional levels. Interactions between levels reflect the importance of simultaneously addressing different level‐specific barriers to smoking cessation in pregnancy. Statement of contribution What is already known on this subject? Few health care professionals discuss smoking cessation support with pregnant or post‐partum women. Identified health care professional‐related barriers to supporting pregnant and post‐partum women to stop smoking include deficits in knowledge and confidence, perceived lack of time, and concerns about damaging client relationships. There is currently a gap in understanding regarding the barriers and facilitators to supporting this group and how interactions between the health care environment and health care professionals influence the way smoking is addressed. What does this study add? This study identifies modifiable factors that can influence cessation support delivery to pregnant and post‐partum women. These factors are mapped across organizational, interpersonal, and individual health care professional levels. Service structure, communication pathways, and policies appear to influence what cessation support is offered. Interpersonal and individual factors influence how this support is delivered.